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United States Department of Transportation United States Department of Transportation

Medical Release Form (Seizure) SAMPLE

About this document

This is a completed sample form which provides authorization to the Federal Motor Carrier Safety Administration to publish seizure exemption information in a public docket.

DOT is committed to ensuring that information is available in appropriate alternative formats to meet the requirements of persons who have a disability. If you require an alternative version of files provided on this page, please contact Christine.hydock@dot.gov.
Last updated: Thursday, April 26, 2018